Lymphadenopathy
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American Roentgen Ray Society Images of Lymphadenopathy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Shyam Patel [2];Associate Editor(s)-in-Chief: Amandeep Singh M.D.[3], Raviteja Guddeti, M.B.B.S. [4] Ogechukwu Hannah Nnabude, MD
Synonyms and keywords: Lymph nodes enlarged; Enlarged lymph nodes; Lymphadenitis; Swollen lymph nodes; Swollen/enlarged lymph nodes
For patient information, click here
Overview
Lymphadenopathy, also called adenopathy, refers to any disease process that involves lymph nodes that are abnormal in consistency and size. This condition has multiple causes, the most common of which include neoplasia, autoimmune diseases, and infection. Lymphadenitis refers to lymphadenopathies that are due to inflammatory processes. It is characterized by nodal swelling, pain, skin changes, fever, edema, and/or purulent collections. [1]
Classification
Lymphadenopathy may be classified as follows:
- By location:
- Dermatopathic lymphadenopathy: lymphadenopathy associated with skin disease.
- By malignancy: Benign lymphadenopathy is distinguished from malignant types which mainly refer to lymphomas or lymph node metastasis.
- By extent:
- Localized lymphadenopathy: due to localized spot of infection
- Generalized lymphadenopathy: due to systemic infection of the body. In some cases, it may persist for prolonged periods possibly without an apparent cause
- By size, where lymphadenopathy in adults is often defined as a short axis of one or more lymph nodes is greater than 10mm.[2][3] However, there is regional variation as detailed in this table:
| Generally | 10 mm[2][3] |
| Inguinal | 10[4] – 20 mm[5] |
| Pelvis | 10 mm for ovoid lymph nodes, 8 mm for rounded[4] |
| Neck | |
|---|---|
| Generally (non-retropharyngeal) | 10 mm[4][6] |
| Jugulodigastric lymph nodes | 11mm[4] or 15 mm[6] |
| Retropharyngeal | 8 mm[6]
|
| Mediastinum | |
| Mediastinum, generally | 10 mm[4] |
| Superior mediastinum and high paratracheal | 7mm[7] |
| Low paratracheal and [[subcarinal] | 11 mm[7] |
| Upper abdominal | |
| Retrocrural space | 6 mm[8] |
| Paracardiac | 8 mm[8] |
| Gastrohepatic ligament | 8 mm[8] |
| Upper paraaortic region | 9 mm[8] |
| Portacaval space | 10 mm[8] |
| Porta hepatis | 7 mm[8] |
| Lower paraaortic region | 11 mm[8] |
Pathophysiology
Lymph nodes are a part of the reticuloendothelial (RES) system, which includes lymphatic vessels, lymphatic fluid found in interstitial fluid, monocytes of the blood, macrophages of the connective tissue, bone marrow, thymus, spleen, bone, and mucosa-associated lymphoid tissue (MALT) of visceral organs [9]
Lymphatic fluid moves throughout the lymphatic system and enters lymph nodes for filtration of foreign antigen. Foreign antigens are presented to the lymphoid cells, which lead to cellular proliferation and enlargement. Under microscopy, cellular proliferation in lymphoid follicles may be identified as several mitotic figures.[10] Increased activity leads to stretching of the lymphatic capsule and this may cause localized tenderness.
The development of B-cells originates from pluripotent stem cells from the bone marrow. B cells that successfully build their immunoglobulin heavy chains migrate to the germinal centers to allow for antibody diversification by somatic hypermutation.[11] The current school of thought is that B-cell lymphomas occur as a result of alternations in chromosomal translocations and somatic hypermutation.
T-cell development also begins from pluripotent stem cells, which mature within the thymic cortex. [12] While they are in the thymic cortex, specific rearrangements occur at the T-cell receptor. It is understood that chromosomal translocations at the level of T-cell receptors lead to T-cell lymphomagenesis.
Lymph nodes follicle necrosis may occur due to inflammatory, infectious, or malignant conditions. The neutrophil-rich infiltrates suggests bacterial infection, while lymphocyte-rich predominance may suggest viral infection. However, clinicians must remember that etiologies may vary; lymphomas, leukemias, tuberculosis, or even systemic lupus erythematosus (SLE) may be more appropriate diagnoses in the appropriate clinical context [13]
Histopathology
Histology can provide more information regarding the cause of lymphadenopathy when etiology is not clear during initial history taking, physical examination, and laboratory evaluation.
Common causes of lymphadenopathy with their associated histological findings include:
- Bacterial lymphadenitis: Neutrophil-rich infiltrate can be found within the sinus and medullary cords. Follicular hyperplasia can be seen as well. [14] [15]
- Viral lymphadenopathy: Macrophage infiltration and lymphoid hyperplasia. Necrosis can be seen in those who are immunocompromised.[16]
- Sarcoidosis: Non-caseating granulomas which replace the normal architecture of the lymph node
- Non-Hodgkin lymphoma: There is partial or widespread loss of the lymph node by a single cell lineage. Lymphoid cells can either proliferate in a disorderly manner or as those that mimic follicular center structures.
- Hodgkin lymphoma: Can be classified by the histological appearance (from most common to least):[17]
- Nodular-sclerosing
- Mixed cellularity
- Lymphocyte-rich
- Lymphocyte-depleted
Causes
Lymph node enlargement can be of viral, bacterial, malignant, protozoan origin and can even be caused by live vaccines [18] Examples of infections that can cause lymph node enlargement include:
- Viral infections such as Epstein-Barr Virus and cytomegalovirus which cause infectious mononucleosis, [19] and CMV mononucleosis respectively.[20]
as well HHV8 [21] and HIV.[22]
- Yersinia pestis, which causes the bubonic plague, causes lymph node swelling so large that it can be seen under the skin. These lymph nodes are called buboes and may become necrotic. [23]
- Other bacterial infections such as cat-scratch disease, [24] cutaneous anthrax, [25] and tuberculous lymphadenitis [26]
- Protozoal infections including African sleeping sickness, [27] Chagas' Disease, [28] and toxoplasmosis. [29]
Examples of malignancies that cause lymphadenopathy are:
- Primary: Hodgkin lymphoma [30] and non-Hodgkin lymphoma give lymphadenopathy in all or a few lymph nodes.[31]
- Secondary: metastasis, Virchow's Node, neuroblastoma, [32] and chronic lymphocytic leukemia.[33]
Autoimmune causes include: systemic lupus erythematosus [34] and rheumatoid arthritis may have a generalized lymphadenopathy.[31]
Benign lymphadenopathy
Examples include:
- Reactive Follicular hyperplasia [35]
- Atypical Follicular Hyperplasia [35]
- IgG4-related sclerosing disease-associated lymphadenopathy [35]
- Paracortical hyperplasia/Interfollicular hyperplasia: It is seen in viral infections, skin diseases, and nonspecific reactions. [35]
- Sinus histiocytosis: It is seen in lymph nodes draining limbs, inflammatory lesions, and malignancies. [35]
- Benign lymphadenopathy with extensive necrosis [35]
Axillary lymphadenopathy can be defined as solid nodes measuring more than 15 mm without fatty hilum.[36] Axillary lymph nodes may be normal up to 30 mm if consisting largely of fat.[36]
In children, a short axis of 8 mm can be used.[37] However, inguinal lymph nodes of up to 15 mm and cervical lymph nodes of up to 20 mm are generally normal in children up to age 8–12.[38]
Lymphadenopathy of more than 1.5 cm - 2 cm increases the risk of cancer or granulomatous disease as the cause rather than only inflammation or infection. Still, an increasing size and persistence over time are more indicative of cancer.[39]
Differentiating Lymphadenopathy from other Diseases
After a thorough history and physical examination, lymphadenopathy can be initially categorized as:
Diagnostic: where in the practitioner has a proximal cause for the lymph nodes and can go on to treat them. Examples would be strep pharyngitis or localized cellulitis. The lymphadenopathy pattern history and physical examination can be suggestive an example would be mononucleosis wearing the practitioner has strong clinic index of suspicion can perform a confirmatory test which if positive he can go on and treat the patient.
Unexplained lymphadenopathy. Unexplained lymphadenopathy can be generalized into localized or generalized lymphadenopathy. Unexplained localized lymphadenopathy is further divided into patterns at no risk for malignancy or serious illness in which case the patient can be observed for 3 to 4 weeks and if response or improvement can be followed. The other alternative is if the patient is found to have a risk for malignancy or serious illness biopsy is indicated
Unexplained generalized lymphadenopathy can be approached after review of epidemiological clues and medications with initial testing with a CBC with manual differential and mononucleosis serology if either is positive and diagnostic proceed to treatment. If both are negative, the second workup approach would be a PPD, and RPR, a chest x-ray, and ANA, hepatitis BS antigen serology, and HIV. Additional testing modalities and lab tests may be indicated depending on clinical cues. If the results of this testing are conclusive, the practitioner can proceed on to diagnosis and treatment at the illness. If the results of the testing are still not clear, proceed onto biopsy of the most abnormal if the nodes.The most functional way to investigate the differential diagnosis of lymphadenopathy is to characterize it by node pattern and location, obtained pertinent history including careful evaluation of epidemiology, and place the patient in the appropriate arm of the algorithm to evaluate lymphadenopathy.
Generalized Lymphadenopathy
Common Infective Causation
- Mononucleosis
- HIV
- Tuberculosis
- Typhoid fever
- Syphilis
- Plague
Malignancies
- Acute leukemia
- Hodgkin's lymphoma
- Non-Hodgkin's lymphoma
Metabolic Storage Disorders
- Gaucher disease
- Niemann-Pick disease
Medication Reactions
- Allopurinol
- Atenolol
- Captopril
- Carbamazepine
- Cephalosporin(s)
- Gold
- Hydralazine
- Penicillin
- Phenytoin
- Primidone
- Pyrimethamine
- Quinidine
- Sulfonamides
- Sulidac
Autoimmune Disease
- Sjogren syndrome
- Sarcoidosis
- Rheumatoid arthritis
- Systemic lupus erythematosus
Localized Peripheral Lymphadenopathy
Head and Neck Lymph Nodes
Viral infection
- Viral URI
- Mononucleosis
- Herpes virus
- Coxsackievirus
- Cytomegalovirus
- HIV
Bacterial infection
- Staphylococcal aureus
- Group A Streptococcus pyogenes
- Mycobacterium
- Dental abscess
- Cat scratch disease
Malignancy
- Hodgkin disease
- Non-Hodgkin lymphoma
- Thyroid cancer
- Squamous cell carcinomas of the head and neck
Inguinal Peripheral Lymphadenopathy
Infection
- STDs
- Cellulitis
Malignancy
- Lymphoma
- Squamous cell carcinoma of genitalia
- Malignant melanoma
Axillary Lymphadenopathy
Infection
- Localized Staphylococcal aureus
- Cat-scratch disease
- Brucellosis
Malignancy
- Lymphoma
- Breast cancer
- Melanoma
- Reaction to breast implants
Supraclavicular Adenopathy
- Infections
- Mycobacteria
- Fungi
- Malignancy
Thoracic and abdominal neoplasms
- Hodgkin disease
- Non-Hodgkin lymphoma
Epidemiology and Demographics
Generalities can safely be made about the epidemiology of lymphadenopathy. [40] [41] [42]
First, both generalized and localized lymphadenopathies are fairly equally distributed without regard to gender.
Second, lymphadenopathy is more prevalent in the pediatric population than in the adult population secondary to the greater number of viral infections. It would follow that the majority of the time, lymphadenopathy in the pediatric population is of less consequence again secondary to the prevalence of viral and bacterial infections in that age group. Three-quarters of all lymphadenopathy observed are localized, and of those three-quarters, half of these are localized to the head and neck area. All remaining localized lymphadenopathy is found in the inguinal area, and the remaining lymphadenopathy is found in the axilla in the supraclavicular area. Of note, the differential diagnosis of lymphadenopathy changes significantly with the age of the patient.
Third, the patient's location and circumstance are very revealing and lymphadenopathy. For example, in the developing world (sub-Saharan Africa, Southeast Asia, Indian subcontinent), exposure to parasites, HIV, and miliary TB are far more likely to be causes of generalized lymphadenopathy then in the United States and Europe. Whereas, Epstein-Barr virus, streptococcal pharyngitis, and some neoplastic processes are more likely candidates to cause lymphadenopathy in the United States and the remainder of the localized industrial world. An exposure history is very important for diagnosis.
Exposure to blood and blood-borne products either through transfusion, unsafe sexual practices, intravenous drug abuse, or vocation Exposure to infectious disease whether it be travel, in the workplace, or the home Medication exposure-prescription, nonprescription, or supplements Exposure to animal-borne illness either via pets or the workplace Exposure to arthropod bites
Natural History, Complications and Prognosis
The prognosis of lymphadenopathy depends on its etiology. While many are treatable are have a good prognosis, malignancies, HIV, active tuberculosis, have less favorable prognoses. Localized lymphadenopathies often have a better prognosis than the majority of generalized lymphadenopathies secondary to etiologies. Also, earlier detection is a crucial determinant of prognosis
Diagnosis
Laboratory Evaluation of Lymphadenopathy
- CBC with manual differential: This is a foundational test in the diagnosis of both generalized and regional lymphadenopathy. The number and differential of the white blood cells can indicate bacterial, viral, or fungal pathology. In addition, characteristic white blood cell (WBC) patterns are observed with several of the hematological neoplasms producing lymphadenopathy
- EBV serology: Epstein-Barr viral mono is present causing regionalized lymphadenopathy
- Sedimentation rate: A measure of inflammation though not diagnostic, it can contribute to diagnostic reasoning
- Cytomegalovirus titers: This viral serology is indicative of possible of CMV mononucleosis
- HIV serology: This serology can be used to diagnose acute HIV syndrome-related lymphadenopathy or to infer the diagnosis of secondary HIV-elated pathologies causing lymphadenopathy.
- Bartonella henselae serology: used for the diagnosis of cat-scratch lymphadenopathy
- FTA\RPR: These tests can diagnose syphilis as the cause of lymphadenopathy
- Herpes simplex serology: can determine if the lymphadenopathy is herpes-related. Herpes simplex can produce symptoms that are similar to mononucleosis.
- Toxoplasmosis serology: can be used to diagnose toxoplasmosis
- Hepatitis B serology: Serological tests for hepatitis B to establish it as a contributing factor for lymphadenopathy
- ANA: this is a screening test for SLE that can help establish it as a cause for generalized lymphadenopathy
Diagnostic Radiological Testing
- Chest x-ray: can reveal tuberculosis, pulmonary sarcoidosis, and pulmonary neoplasm.
- Chest CT scan: This modality of radiological imaging can define the above processes and reveal hilar adenopathy.
- Abdominal and pelvic CT scan: These images, in combination with chest CT scan, can be revealing in cases of supraclavicular adenopathy and the diagnosis of secondary neoplasm.
- Ultrasonography: can be used in the assessment of number, size, size, shape, the marginal definition, and internal structures in patients with lymphadenopathy. Color Doppler ultrasonography is of use in distinguishing the vascular pattern between more established, pre-existing lymphadenopathy and acute lymphadenopathy. Studies have indicated that a low long axis to short axis ratio of lymphadenopathy as measured by ultrasound can be a significant indicator of lymphoma and metastatic cancer as a cause of lymphadenopathy.
- MRI scanning: useful in the evaluation of thoracic, abdominal, and pelvic masses.
- PPD: can be used in diagnosis of tuberculosis
- Tissue diagnosis of the node: this is done by incisional biopsy and remains gold standard for diagnosis of lymphadenopathy.
Treatment
Treatment of lymphadenopathy is based on the etiology. Generally, treatment of lymphadenopathy is as follows:
- Infectious causes of lymphadenopathy can be treated with antibiotic therapy, antiviral therapy, or antifungal therapy.
- Immune therapy, systemic glucocorticoids can be used for autoimmune causes of lymphadenopathy
- For malignancies, any combination of surgery, chemotherapy, and radiation therapy can be used.
- If medication is the suspected cause, discontinue the medication if possible.
References
- ↑ Gosche JR, Vick L (2006). "Acute, subacute, and chronic cervical lymphadenitis in children". Semin Pediatr Surg. 15 (2): 99–106. doi:10.1053/j.sempedsurg.2006.02.007. PMC 7111159 Check
|pmc=value (help). PMID 16616313. - ↑ 2.0 2.1 Ganeshalingam, Skandadas; Koh, Dow-Mu (2009). "Nodal staging". Cancer Imaging. 9 (1): 104–111. doi:10.1102/1470-7330.2009.0017. ISSN 1470-7330. PMC 2821588. PMID 20080453.
- ↑ 3.0 3.1 Schmidt Júnior, Aurelino Fernandes; Rodrigues, Olavo Ribeiro; Matheus, Roberto Storte; Kim, Jorge Du Ub; Jatene, Fábio Biscegli (2007). "Distribuição, tamanho e número dos linfonodos mediastinais: definições por meio de estudo anatômico". Jornal Brasileiro de Pneumologia. 33 (2): 134–140. doi:10.1590/S1806-37132007000200006. ISSN 1806-3713. PMID 17724531.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 Torabi M, Aquino SL, Harisinghani MG (September 2004). "Current concepts in lymph node imaging". Journal of Nuclear Medicine. 45 (9): 1509–18. PMID 15347718.
- ↑ "Assessment of lymphadenopathy". BMJ Best Practice. Retrieved 2017-03-04. Last updated: Last updated: Feb 16, 2017
- ↑ 6.0 6.1 6.2 Page 432 in: Luca Saba (2016). Image Principles, Neck, and the Brain. CRC Press. ISBN 9781482216202.
- ↑ 7.0 7.1 Sharma, Amita; Fidias, Panos; Hayman, L. Anne; Loomis, Susanne L.; Taber, Katherine H.; Aquino, Suzanne L. (2004). "Patterns of Lymphadenopathy in Thoracic Malignancies". RadioGraphics. 24 (2): 419–434. doi:10.1148/rg.242035075. ISSN 0271-5333. PMID 15026591.
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 Dorfman, R E; Alpern, M B; Gross, B H; Sandler, M A (1991). "Upper abdominal lymph nodes: criteria for normal size determined with CT". Radiology. 180 (2): 319–322. doi:10.1148/radiology.180.2.2068292. ISSN 0033-8419. PMID 2068292.
- ↑ Mohseni S, Shojaiefard A, Khorgami Z, Alinejad S, Ghorbani A, Ghafouri A (2014) Peripheral lymphadenopathy: approach and diagnostic tools. Iran J Med Sci 39 (2 Suppl):158-70. PMID: 24753638
- ↑ Gowing NF (1974). "Tumours of the lymphoreticular system: nomenclature, histogenesis, and behaviour". J Clin Pathol Suppl (R Coll Pathol). 7: 103–7. PMC 1347234. PMID 4598345.
- ↑ Mesin L, Ersching J, Victora GD (2016). "Germinal Center B Cell Dynamics". Immunity. 45 (3): 471–482. doi:10.1016/j.immuni.2016.09.001. PMC 5123673. PMID 27653600.
- ↑ Kumar BV, Connors TJ, Farber DL (2018) Human T Cell Development, Localization, and Function throughout Life. Immunity 48 (2):202-213. DOI:10.1016/j.immuni.2018.01.007 PMID: 29466753
- ↑ Strickler JG, Warnke RA, Weiss LM (1987). "Necrosis in lymph nodes". Pathol Annu. 22 Pt 2: 253–82. PMID 3317224.
- ↑ Fend F, Cabecadas J, Gaulard P, Jaffe ES, Kluin P, Kuzu I; et al. (2012). "Early lesions in lymphoid neoplasia: Conclusions based on the Workshop of the XV. Meeting of the European Association of Hematopathology and the Society of Hematopathology, in Uppsala, Sweden". J Hematop. 5 (3). doi:10.1007/s12308-012-0148-6. PMC 3845020. PMID 24307917.
- ↑ Elmore SA (2006) Histopathology of the lymph nodes. Toxicol Pathol 34 (5):425-54. DOI:10.1080/01926230600964722 PMID: 17067938
- ↑ Lucia HL, Griffith BP, Hsiung GD (1985) Lymphadenopathy during cytomegalovirus-induced mononucleosis in guinea pigs. Arch Pathol Lab Med 109 (11):1019-23. PMID: 2996461
- ↑ Eberle FC, Mani H, Jaffe ES (2009). "Histopathology of Hodgkin's lymphoma". Cancer J. 15 (2): 129–37. doi:10.1097/PPO.0b013e31819e31cf. PMID 19390308.
- ↑ (2015) Reorganized text. JAMA Otolaryngol Head Neck Surg 141 (5):428. DOI:10.1001/jamaoto.2015.0540 PMID: 25996397
- ↑ Weiss LM, O'Malley D (2013). "Benign lymphadenopathies". Mod Pathol. 26 Suppl 1: S88–96. doi:10.1038/modpathol.2012.176. PMID 23281438.
- ↑ Sinha AK, Lovett M, Pillay G (1970). "Cytomegalovirus infection with Lymphadenopathy". Br Med J. 3 (5715): 163. doi:10.1136/bmj.3.5715.163. PMC 1702272. PMID 4317237.
- ↑ O'Leary J, Kennedy M, Howells D, Silva I, Uhlmann V, Luttich K; et al. (2000). "Cellular localisation of HHV-8 in Castleman's disease: is there a link with lymph node vascularity?". Mol Pathol. 53 (2): 69–76. doi:10.1136/mp.53.2.69. PMC 1186908. PMID 10889905.
- ↑ Oksenhendler E, Duarte M, Soulier J, Cacoub P, Welker Y, Cadranel J; et al. (1996). "Multicentric Castleman's disease in HIV infection: a clinical and pathological study of 20 patients". AIDS. 10 (1): 61–7. PMID 8924253.
- ↑ Butler T (2009). "Plague into the 21st century". Clin Infect Dis. 49 (5): 736–42. doi:10.1086/604718. PMID 19606935.
- ↑ Klotz SA, Ianas V, Elliott SP (2011). "Cat-scratch Disease". Am Fam Physician. 83 (2): 152–5. PMID 21243990.
- ↑ Sweeney DA, Hicks CW, Cui X, Li Y, Eichacker PQ (2011). "Anthrax infection". Am J Respir Crit Care Med. 184 (12): 1333–41. doi:10.1164/rccm.201102-0209CI. PMC 3361358. PMID 21852539.
- ↑ Fontanilla JM, Barnes A, von Reyn CF (2011). "Current diagnosis and management of peripheral tuberculous lymphadenitis". Clin Infect Dis. 53 (6): 555–62. doi:10.1093/cid/cir454. PMID 21865192.
- ↑ Kennedy PG (2013) Clinical features, diagnosis, and treatment of human African trypanosomiasis (sleeping sickness). Lancet Neurol 12 (2):186-94. DOI:10.1016/S1474-4422(12)70296-X PMID: 23260189
- ↑ Salazar Schettino PM, Bucio Torres M, Cabrera Bravo M, Ruiz Hernández AL (2011). "[Chagas disease in Mexico. Report of two acute cases]". Gac Med Mex. 147 (1): 63–9. PMID 21412398.
- ↑ Montoya JG, Liesenfeld O (2004). "Toxoplasmosis". Lancet. 363 (9425): 1965–76. doi:10.1016/S0140-6736(04)16412-X. PMID 15194258.
- ↑ Glass, C (September 2008). "Role of the Primary Care Physician in Hodgkin Lymphoma". American Family Physician. 78 (5): 615–622. PMID 18788239.
- ↑ 31.0 31.1 Status and anamnesis, Anders Albinsson. Page 12
- ↑ Colon, NC; Chung, DH (2011). "Neuroblastoma". Advances in Pediatrics. 58 (1): 297–311. doi:10.1016/j.yapd.2011.03.011. PMC 3668791. PMID 21736987.
- ↑ Sagatys, EM; Zhang, L (January 2011). "Clinical and laboratory prognostic indicators in chronic lymphocytic leukemia". Cancer Control. 19 (1): 18–25. doi:10.1177/107327481201900103. PMID 22143059.
- ↑ Melikoglu, MA; Melikoglu, M (October–December 2008). "The clinical importance of lymphadenopathy in systemic lupus erythematosus" (PDF). Acta Reumatologia Portuguesa. 33 (4): 402–406. PMID 19107085.
- ↑ 35.0 35.1 35.2 35.3 35.4 35.5 Weiss, LM; O'Malley, D (2013). "Benign lymphadenopathies". Modern Pathology. 26 (Supplement 1): S88–S96. doi:10.1038/modpathol.2012.176. PMID 23281438.
- ↑ 36.0 36.1 Page 559 in: Wolfgang Dähnert (2011). Radiology Review Manual. Lippincott Williams & Wilkins. ISBN 9781609139438.
- ↑ Page 942 in: Richard M. Gore, Marc S. Levine (2010). High Yield Imaging Gastrointestinal HIGH YIELD in Radiology. Elsevier Health Sciences. ISBN 9781455711444.
- ↑ Laurence Knott. "Generalised Lymphadenopathy". Patient UK. Retrieved 2017-03-04. Last checked: 24 March 2014
- ↑ Bazemore AW, Smucker DR (December 2002). "Lymphadenopathy and malignancy". American Family Physician. 66 (11): 2103–10. PMID 12484692.
- ↑ Siddiqui S, Osher J (2017). "Assessment of Neck Lumps in Relation to Dentistry". Prim Dent J. 6 (3): 44–50. doi:10.1308/205016817821931079. PMID 30188316.
- ↑ Loizos A, Soteriades ES, Pieridou D, Koliou MG (2018). "Lymphadenitis by non-tuberculous mycobacteria in children". Pediatr Int. 60 (12): 1062–1067. doi:10.1111/ped.13708. PMID 30290041.
- ↑ Prudent E, La Scola B, Drancourt M, Angelakis E, Raoult D (2018). "Molecular strategy for the diagnosis of infectious lymphadenitis". Eur J Clin Microbiol Infect Dis. 37 (6): 1179–1186. doi:10.1007/s10096-018-3238-2. PMID 29594802.